Friday, January 1, 2010

DG Health Ismail Merican: 1MALAYSIA CLINICS: Urban poor need shot in the arm

1MALAYSIA CLINICS: Urban poor need shot in the arm

NST: 2010/01/01
TAN SRI DR MOHD ISMAIL MERICAN, Director-general of Health

SEVERAL letters have been published expressing concerns over the establishment of 1Malaysia clinics by the government.

The Malaysian Medical Association president wrote that it was being done in haste without due thought to the role these clinics will play.

He and another writer, a fourth-year medical student, felt that the Health Ministry was taking a step backwards by having paramedics and staff nurses run these clinics.

It saddens me to read their exhortations, one a presumably experienced clinician in the private sector and the other a student who has yet to earn his stripes as a doctor. While both mean well, they should have given some thought to what they are writing.

Suggesting that the ministry had acted in haste and is being retrogressive in its approach clearly reflects their lack of understanding of the role of the 1Malaysia clinics.

I would like to shed some light on the 1Malaysia clinics so that Malaysians will be assured that by establishing these clinics in urban settings, we are helping to meet the urgent health needs of the rakyat.

Rural Malaysians receive better healthcare than their poorer urban counterparts.
Rural Malaysians receive better healthcare than their poorer urban counterparts.

Malaysia has a dichotomous healthcare system. People have the option of either going to government-run clinics and hospitals or the private sector. Many throng our health clinics and almost all have to wait long hours to get served, even for minor ailments or simple procedures.

The ministry extended the hours of outpatient services until 9.30pm at selected busy clinics. We have also opened our clinics during lunch hour for patients' convenience.

One of the ministry's primary objectives is to ensure the delivery of equitable quality healthcare to the rakyat.

The establishment of the 1Malaysia clinics was certainly not done in haste. In nations throughout the world, there is a progressive migration from rural to urban areas. Malaysia is no exception. It is estimated that by 2015, more than 50 per cent of the population will be living in urban settings.

With the migration of people to urban areas, there is a growing concern for the plight and specific health needs of the urban poor. Many face various socio-economic problems, including access to quality healthcare.

Malaysia has often been cited by the World Health Organisation as having one of the best rural healthcare services, with strategically located rural clinics making quality healthcare accessible.

Many are managed by paramedics, that is, assistant medical officers (previously called medical assistants) and staff nurses, under the supervision of a doctor stationed at a larger nearby clinic. This doctor is responsible for ensuring that the care delivered by the paramedics is in accordance with good medical practice.

This system has stood the test of time and it was felt that a similar structure would now be appropriate to cater for the needs of the urban poor, many of whom do not have access to the services enjoyed by those in rural areas.

A task force comprising senior officers from the relevant divisions of the ministry, who are well versed in the current strengths and limitations of our existing healthcare delivery in urban areas, drew up comprehensive guidelines for the establishment and running of these clinics.

It was to address this need that the idea of 1Malaysia clinics was put forward. Such clinics will fulfil the government's social responsibility of delivering equitable healthcare to every Malaysian.

This proactive step to address the growing health needs of the urban poor will alleviate the suffering of those who require urgent attention for minor ailments.

The paramedics manning these clinics are experienced officers who know their limitations and are able to detect clinical conditions that would require urgent referral to doctors. We have enlisted a group of doctors, both in the public and private sectors, in the vicinity of these clinics, to see such patients where necessary.

In addition, a doctor will be held responsible for ensuring that the treatment provided by the paramedics is proper, in accordance with the established guidelines and procedures, and meets our standards.

To belittle the capability of the paramedics and staff nurses in handling minor illnesses is unfair and reflects ignorance of the role of these healthcare providers in our healthcare delivery system.

There are clear job descriptions for staff nurses and assistant medical officers. They are qualified to carry out minor surgical procedures and are allowed to use specific surgical instruments under the Medical Act 1971.

Their role in these clinics is within their current scope of work at hospitals and clinics. They will not be asked to take on more than they have been trained for and will adhere to the guidelines on the type of services that can be offered at all times.

With the setting up of these clinics, one need not take an elderly relative to a large clinic or hospital to change a bladder catheter or dress a minor injury sustained at home, school or at work.

A 1Malaysia clinic, which operates from 10am to 10pm daily, can get this done promptly without the hassle of looking for transport. These clinics will be situated in areas where there is a concentration of urban poor.

While some are questioning the use of paramedics, there is a growing trend in most developed countries such as Australia and the United Kingdom to delegate the routine follow- ups and monitoring of stable patients with chronic illness such as diabetes, asthma, hypertension and even stable heart failure to staff nurses.

Our 1Malaysia clinics will similarly be able to offer point-of-care tests to help monitor the status of patients with chronic illnesses and, when necessary, initiate a referral either to a family physician or to a hospital for definitive care. Of course, they have to be trained and supervised by a doctor in the course of their work.

Having staff nurses to help monitor these patients is not a move backwards, but a move forward in keeping with changing trends of medical care.

I would like to reassure the public and the medical fraternity that the ministry gave this a lot of thought.

It is not our intention to take the business of healthcare away from our primary care doctors. On the contrary, we have proposed that the government introduce an integrated primary healthcare system so the rakyat can seek treatment from doctors in both public and private sectors.

We hope to introduce the concept of a "family doctor" and have taken steps to encourage our primary care doctors to become effective "gatekeepers".

While waiting for that to materialise, we need to urgently address the health needs of the urban poor, and having the 1Malaysia clinics, just 50 of them throughout the country (three or four in each state) is not going to dent the purse of our doctors.

Let me reiterate that although we would like to provide convenience to the rakyat, we will not compromise on the standards of care.

Let us all give the 1Malaysia clinics a chance to prove their worth. Should there be any infringements of quality of care, we can always put in remedial measures. We are open to feedback from all.

Should any of you have good ideas on how we can provide better healthcare for you, please let us know. We are ready to serve you better.


Bushido said...

Does the DG mean that it is perfectly okay for MA to dispense Pseudoephedrine to the patients in 1 Malaysia Clinics while down the road, the GP must personally hand it to his patient or he will be censured by the DEA ?

Can the GP employ a MA to run his clinic as a locum under the PHFSA ?

dranony said...

If MAs at 1Malaysia clinics are allowed to dress wounds eg sustained from a fall from a motorbike, will/can the patient be covered with MC?
Under Medical Act 1971, only doctors can sign MCs.
What about if the accident victim claims insurance? Can an MA write a Medical Report? Medical Act 1971 states that only doctors can furnish medical reports.

DG proposes that MAs can followup patients with chronic diseases like hypertension and diabetes, etc.
Poisons Act 1952 states that certain medications, and these include MOST of the medications for HPT & DM, are under Group B of the Poisons Schedule, which CANNOT be dispensed except by doctors or registered pharmacists.
Can the 1Malaysia clinics simply "dispense with" (pun intended) the law, esp Poisons Act 1952?

Will MAs running 1Malaysia clinics thus be running these clinics in violation of Medical Act 1971, as well as Poisons Act 1952?

Previously the MMC, under the DG, had taken severe action against private doctors employing MAs, for "infamous conduct" or "unprofessional conduct" in breach of MMC's own Code of Professional Conduct.
YET, the DG is now in defence of, even promoting, such "unprofessional conduct!"
Reeks of double standards, doesn't it?